NURSING 620 ADVANCE PHYSICAL ASSESSMENT FINALS

NURSING 620 ADVANCE PHYSICAL ASSESSMENT FINALS 1 What step of the nursing process includes data collection by heath history, physical examination, and interview? a Planning b Diagnosis c Evaluation d Assessment1/7 q 16 2 The nurse is performing a physical assessment on newly admitted patient. An example of objective information obtained during the physical assessment includes: a Patient’s history of allergies b Patients use of medication at home c Last menstrual period 1 month ago. d 2x5 cm scar on the right lower forearm.1/7 q 21 3 A 42-year old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a Identify the cause of his illness. b Make accurate disease diagnoses. c Provide cultural health rights for the individual. d Provide culturally sensitive and appropriate care.1/9 q 26 4 In the health promotion model, the focus of the health professional includes: a Changing the patient’s perception of disease. b Identifying biomedical model interventions. c Identifying negative health acts of the consumer. d Helping the consumer choose a healthier lifestyle. 1/9 q 27 5 The nursing process is a sequential method of problem solving that nurses use and includes which steps. a Assessment, treatment, planning, evaluation, discharge, and follow up b Admission, assessment, diagnosis, treatment, and discharge planning. c Admission, diagnosis, treatment, evaluation, and discharge planning. d Assessment, diagnosis, outcome identification, planning, implementation, and evaluation.1/4 q 12 6 The nurse is preparing to conduct a health history. Which of this statements best describes the purpose of health history? a To provide an opportunity for interaction between the patient and the nurse. b To provide a form for obtaining the patients biographic information c To document the normal and abnormal findings of a physical assessment. d To provide a database of subjective information about the patients past and current health.4/1 q 1 7 A patient tell the nurse that he is allergic to penicillin. What would be the nurse’s best response to this information? a “Are you allergic to any other drugs?” b “How often have you received penicillin?” c “I’ll write your allergy on your chart so you won’t receive any penicillin.” d “Describe what happen to you when you take penicillin”4/3 q 8 8 The nurse is asking a patient for his reason for seeking care and ask a about the signs and symptoms he is experiencing. Which of this is an example of a symptoms? a Chest pain 4/10 q 27 b Clammy skin c Serum potassium level at 4.2 mEq/L d Body temperature of 100 deg F 9 When performing a physical assessment, the first technique the nurse will always use is: a Palpation b Inspection 8/1 q 1 c Percussion d Auscultation 10 The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patients skin temperature? a Fingertips; they are more sensitive to small changes in temperature. b Dorsal surface of the hand; the skin is thinner on this surface than on the palm 8/2 q 3. c Ulnar portion of the hand; increased blood supply in this area enhances temperature sensitivity. d Palmar surface of the hand; this surface is the most sensitive to temperature variations because of it’s increased nerve supply in this area. 11 Which of this techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient? a Palpation 8/2 q 4 b Auscultation c Inspection d Percussion 12 The nurse is preparing to assess a patients abdomen by palpitation. How should the nurse proceed? a Palpation of reportedly “tender” areas are avoided because palpation in these areas may cause pain. b Palpating a tender area is quickly performed to avoid any discomfort that the patient may experience. c The assessment begins with deep palpation, while encouraging the patient to relax and to take deep breaths. d The assessment begins with light palpation to detect surface characteristics and to accustom the patient to being touched.8/2 q 5 13 The nurse would use bimanual palpation technique in which situation? a Palpating the thorax of an infant. b Palpating the kidneys and uterus 8/2 q 6 c Assessing pulsations and vibrations d Assessing the presence of tenderness and pain.4444 14 The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the of the underlying tissue. a Turgor b Texture c Density 8/3 q 7 d Consistency 15 The nurse is preparing to use stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope? The diaphragm: a Is used to listen for high-pitched sounds8/5 q 14 b Is use listen for low- pitched sounds c Should be lightly held against the person’s skin to block out low pitch-sounds d Should be lightly held against the person’s skin to listen for extra heart sounds and murmurs. 16 The nurse is preparing to use otoscope for an examination. Which statement is true regarding the otoscope? The otoscope: a Is often used to direct light onto the sinuses. b Uses a short broad speculum to help visualize the ear. c Is use to examine the structure of the internal ear. d Directs light into the ear canal and onto the tympanic membrane.8/6 q 17 17 An examiner is using an ophthalmoscope to examine a patient’s eyes. The patient has astigmatism and is nearsighted. The use of which of these techniques would indicate that the examination is being correctly performed? a Using the large full circle of light when assessing pupils that are not dilated b Rotating the lens selector dial to the black numbers to compensate for astigmatism c Using the grid on the lens aperture dial to visualize the external structure of the eye d Rotating the lens selector to bring the object into focus.8/7 q 18 18 The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse: a Performed the examination from the left side of the bed. b Examines tender or painful areas first to help to relieve the patient’s anxiety. c Follows the same examination sequence, regardless of the patient’s age or condition. d Organizes the assessment to ensure that a patient does not change positions too often. 8/7 q 20 19 The nurse keeps in mind that the most important reason to share information and to offer brief teaching while performing the physical examination is to help the: a Examiner feel more comfortable and to gain control of the situation. b Examiner to build rapport and to increase the patient’s confidence in him or her.8/9 q 25 c Patient understands his or her disease process and treatment modalities. d Patient identify questions about his or her disease and the potential areas of patient education. 20 When examining a 16 year old male teenager, the nurse should: a Discuss health teaching with the parent because the teen is unlikely to be interested in promoting wellness. b Ask his parent to stay in the room during the history and physical examination to answer any question and to alleviate his anxiety. c Talk to him the same manner as one would talk to younger child because a teens level of understanding may not match his or her speech. d Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rate and development. 8/12 q 33 21 When examining an older adult, the nurse should use which technique: a Avoid touching the patient too much b Attempt to perform the entire physical examination during one visit c Speak loudly and slowly because most aging adults have hearing deficits. d Arrange the sequence of the examination to allow as few position changes as possible.8/12 q 34 22 While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur? a Electrocardiogram b Bell of the stethoscope8/14 q 39 c Diaphragm of the stethoscope d Palpation with the nurse’s palm of the hand 23 During an examination of a patient’s abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. This type of sound indicates: a Constipation. b Air-filled areas.8/15 q 40 c Presence of a tumor. d Presence of dense organs. 24 The nurse is performing a general survey. Which action is a component of the general survey? a Observing the patient’s body stature and nutritional status9/1 q 1 b Interpreting the subjective information the patient has reported c Measuring the patient’s temperature pulse respirations and blood pressure d Observing specific body systems while performing the physical assessment 25 Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a 1 minute, if the rhythm is irregular.9/7 q 19 b 15 seconds and then multiplied by 4, if the rhythm is regular. c 2 full minutes to detect any variation in amplitude. d 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities. 26 A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a Bell palsy. b Damage to the trigeminal nerve. c Frostbite with resultant paresthesia to the cheeks. d Scleroderma. 27 A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN and proceeds with the examination by . a XI; palpating the anterior and posterior triangles b XI; asking the patient to shrug her shoulders against resistance c XII; percussing the sternomastoid and submandibular neck muscles d XII; assessing for a positive Romberg sign 28 When examining a patient’s CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a Sternomastoid and trapezius. b Spinal accessory and omohyoid. c Trapezious and sternomandibular. d Sternomandibular and spinal accessory. 29 A patient’s laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the gland. a Thyroid 13/3 q 8 b Parotid c Adrenal d Parathyroid 30 A patient says that she has recently noticed a lump in the front of her neck below her “Adam’s apple” that seems to be bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a Is tender. b Is mobile and not hard.13/3/q/9 c Disappears when the patient smiles. d Is hard and fixed to the surrounding structures. 31 A 19-year-old college student is brought to the emergency department with a severe headache he describes as, “Like nothing I’ve ever had before.” His temperature is 40deg C, and he has stiff neck. The nurse looks for other signs and symptoms of which problem? a Head injury b Cluster headache c Migraine headache d Meningeal inflammation 13/6 q 16 32 The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a Hyoid bone. b Vagus nerve. c Tragus 13/7 q 18. d Mandible. 33 A patient has come in for an examination and states, “I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?” The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a Thyroid gland. b Parotid gland.13/7 q 19 c Occipital lymph node. d Submental lymph node. 34 A patient’s thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a sound that is heard best with the of the stethoscope. a Low gurgling; diaphragm b Loud, whooshing, blowing; bell c Soft, whooshing, pulsatile sound best heard with bell 13/8 q 23 d High-pitched tinkling; diaphragm 35 During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement a Using gentle pressure, palpate with both hands to compare the two sides.13/13 q 38 b Using strong pressure, palpate with both hands to compare the two sides. c Gently pinch each node between one’s thumb and forefinger, and then move down the neck muscle. d Using the index and the middle fingers, gently palpate by applying pressure in a rotating pattern. 36 During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a Decreased in the older adult. b Impaired in a patient with cataracts. c Stimulated by cranial nerves (CNs) I and II. d Stimulated by CNs III, IV, AND VI.14/1 q 2 37 The nurse is testing a patient’s visual accommodation, which refers to which action? a Pupillary construction when looking at a near object 14/3 q7 b Pupillary dilation when looking at a far object c Changes in peripheral vision in response to light d Involuntary blinking in the presence of bright light 38 A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a The eyes converge to focus on the light. b Light is reflected at the same spot in both eyes. c The eye focuses the image in the center of the pupil. d Constriction of both pupils occurs in response to bright light. 14/3 q 8 39 A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a At 30 feet the patient can read the entire chart. b The patient can read at 20 feet what a person with normal vision can read at 30 feet.14/5 q 14 c The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d The patient can read from 30 feet what a person with normal vision can read from 20 feet. 40 The nurse is examining a patient’s retina with an ophthalmoscope. Which finding is considered normal? a Optic disc that is a yellow-orange color 14/9 q 25 b Optic disc margins that are blurred around the edges c Presence of pigmented crescents in the macular area d Presence of the macula located on the nasal side of the retina 41 A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a Chalazion b Hordeolum (stye). c Dacryocystitis 14/12 q 34. d Blepharitis. 42 An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a Retinal detachment. b Diabetic retinopathy. c Acute-angle glaucoma. d Increased intracranial pressure 14/13 q 37 43 The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a Auricle.15/1 q 1 b Concha. c Outer meatus. d Mastoid process. 44 The nurse is examining a patient’s ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a Sticky honey-colored cerumen is a sign of infection. b The presence of cerumen is indicative of poor hygiene. c The purpose of cerumen is to protect and lubricate the ear. 15/1 q 2 d Cerumen is necessary for transmitting sound through the auditory canal. 45 When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear. a Light pink with a slight bulge. b Pearly gray and slightly concave.15/1 q 1 c Pulled in at the base of the cone of light. d Whitish with a small fleck of light in the superior portion. 46 A patient with a middle ear infection asks the nurse, “What does the middle ear do?” The nurse responds by telling the patient that the middle ear functions to: a Maintain balance. b Interpret sounds as they enter the ear. c Conduct vibrations of sounds to the inner ear 15/2 q 5 d Increase amplitude of sound for the inner ear to function. 47 The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air condition? a Air conduction is the normal pathway for hearing 15/3 q 7. b Vibrations of the bones in the skull cause air conduction c Amplitude of sounds determines the pitch that is heard d Loss of conduction is called a conductive hearing loss 48 The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a Tilting the person’s head forward during the examination b Once the speculum is in the ear, releasing the traction c Pulling the pinna up and back before inserting the speculum 15/8 q 23 d Using the smallest speculum to decrease the amount of discomfort 49 The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a Red and bulging b Hypomobility 15/11 q32 c Retraction with landmarks clearly visible d Flat, slightly pulled in at the center, and moves with insufflations 50 The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a Pulling the pinna down 15/12 q 1 b Pulling the pinna up and back c Slightly tilting the child’s head toward the examiner d Instructing the child to touch his chin to his chest 51 The primary purpose of the ciliated mucous membrane in the nose is to: a Warm the inhaled air. b Filter out dust and bacteria 16/1 q 1 c Filter coarse particles from inhaled air. d Facilitate the movement of air through the nares. 52 In assessing the tonsil of a 30 year old, the nurse notices that they are involuted, granular in appearance. And appear to have deep crypts. What is correct response to this findings? a Refer the patient to a throat specialist. b No response is needed; this appearance is normal for the tonsils.16/2 q 6 c Continue with the assessment, looking for any abnormal findings. d Obtain a throat culture on the patient by possible streptococcal infection. 53 A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur. a Rubella b Leukoplakia c Rheumatic fever 16/13 q 37 d Scarlet fever 54 Which of the following statements is true regarding the internal structures of breast? The breast is made up of: a Primarily muscle with a very little fibrous tissue. b Fibrous grandular, and adipose tissues 17/1 q 1 c Primarily milk ducts, known as lactiferous ducts. d Glandular tissue, which supports the breast by attaching to the chest wall. 55 In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a The largest quadrant of the breast b The location of most breast tumor 17/1 q 2 c Where most of the suspensory ligaments attach d More prone to injury and calcifications than the other locations in the breast. 56 If a patient reports a recent breast infection, then the nurse should expect to find node enlargement. a Nonspecific b Ipsilateral axillary17/2 q 4 c Contralateral axillary d Inguinal and cervical 57 A 65 year old patient remarks that she just cannot believe that her breast “sag so much”. She state it must be from a lack of exercise. What explanation should the nurse offer her? After menopause: a Only women with large breast experience sagging. b Sagging is usually due to decreased muscle mass within the breast. c A diet that is high in protein will help maintain muscle mass, which keeps the breast from sagging. d The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breast that sag 17/4 q 11. 58 The nurse is reviewing risk factor for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer. a 7 year old who is slightly overweight b 42 years old who has ovarian cancer c 45 years old who has never been pregnant d 65 year old whose mother had breast cancer17/8 q 22 59 The nurse is performing a breast examination. Which of this statement that best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have woman: a Bend over and touch her toes b Lie down on her left side and notice any retraction c Shift from a supine position to a standing position, and note any lag or retraction d Slowly lif t her arms above her head, and note any retraction or lag movement.17/10 q 26 60 The nurse is palpating a female patient’s breast during an examination. Which of this positions is most likely to make significant lumps more distinct during breast palpation? a Supine with the arms raised over her head 17/10 q 27. b Sitting with the arms relaxed at her sides c Supine with the arms relaxed at her sides d Sitting with the arms flexed and fingertips touching her shoulders 61 During a discussion about BSEs with a 39 year old woman, which of these statements by the nurse is most appropriate? a The best time to examine your breast is during ovulation. b Examine your breast every month on the same day of the month c Examine you breast shortly after your menstrual period each month 17/14 q 35 d The best time to examine your breast is immediately before menstruation. 62 While examining a 75 year old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a Dimpling b Retraction c Peau d’orange 17/15 q 39 d Benign breast disease 63 Which statement about the apices of the lungs is true? The apices of the lungs: a Are at the level of the second rib anteriority b Extend 3 to 4 cm above the inner third of the clavicles.18/2 q 4 c Are located at the sixth rib anteriorly and the eight rib laterally d Rest on the diaphragm at the fifth intercostals space in the midclavicular line (MCL) 64 When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location. a Between scapulae 18/3 q 9 b Third intercostal space, MCL c Fifth intercostals space, midaxillary line (MAL) d Over the lower lobes, posterior side 65 The nurse is auscultating the chest in an adult. Which technique is correct? a Instructing the patient to take a deep breath, rapid breaths b Instructing the patient to breath in and out through his or her nose c Firmly holding the diaphragm of the stethoscope against the chest18/5 q 14 d Lightly holding the bell of the stethoscope against the chest to avoid friction 66 The nurse knows that a normal finding when assessing the respiratory system of an older adult is: a Increased thoracic expansion b Decreased mobility of the thorax18/6 q 18 c Decreased anteroposterior diameter d Bronchovesicular breath sounds throughout the lungs 67 The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a Wheezes 18/9 q 26 b Bronchial sounds c Bronchopony d Whispered pectoriloquy 68 During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? a Listening to at least one full respiration in each location18/13 q 37 b Listening as the patient inhales and then going to the next site during exhalation c Instructing the patient to breath in and out rapidly while listening to the breath sounds d If the patient is modest, listening to sounds over his or her clothing or hospital gown. 69 The direction of the blood flow through the heart is best described by which of this? a Vena cava->right atrium->right ventricle->lungs->pulmonary artery->left atrium->left ventricle b Right atrium->right ventricle->pulmonary artery->lungs->pulmonary viens->lef t atrium- >lef t ventricle 19/1 q 2 c Aorta->right atrium->right ventricle->lungs->pulmonary vien->left atrium->left ventricle- >vena cava d Right atrium->right ventricle->pulmonary vien->lungs->pulmonary artery->left atrium- >left ventricle 70 When listening to heart sounds. The nurse knows the valve closures that can be heard best at the base of the heart are: a Mitral and tricuspid b Tricuspid and aortic c Aortic and pulmonic19/2 q 4 d Mitral and pulmonic 71 The component of the conduction system referred to as the pacemaker of the heart is the: a Atrioventricular (AV) node. b Sinoatrial (SA) node.19/2 q 6 c Bundle of His. d Bundle branches. 72 During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a Third left intercostal space at the midclavicular line b Fourth left intercostal space at the sternal border c Fourth left intercostal space at the anterior axillary line d Fifth lef t intercostal space at the midclavicular line 19/7 q 18 73 The nurse is preparing to auscultate for heart sounds. What technique is correct? a Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas b Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.19/7 q 20 c Listening to the sounds only at the site where the apical pulse is felt to be the strongest. d Listening for all possible sounds at a time at each specified area. 74 During a cardiovascular assessment, the nurse knows that a thrill is: a Vibration that is palpable.19/13 q 34 b Palpated in the right epigastric area. c Associated with ventricular hypertrophy d Murmur auscultated at the third intercostals space. 75 The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the artery a Ulnar b Radial c Brachial 20/1 q 2 d Deep palmar 76 The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a Behind the knee b Over the lateral malleolus c In the groove behind the medial malleolus d Lateral to the extensor tendon of the great toe 20/1 q 3 77 The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a Intraluminal valves ensure unidirectional flow toward the heart.20/2 q 5 b Contracting skeletal muscles milk blood distally toward the veins. c High-pressure system of the heart helps facilitate venous return. d Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart. 78 The nurse is performing an assessment on an adult. The adult’s vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a Ask the patient about a history of frostbite. b Suspect that the patient has venous insufficiency. c Consider this a delayed capillary refill time, and investigate further.20/6 q17 d Consider this a normal capillary refill time, and investigate further. 79 During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with non- pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? a Venous stasis b Lymphedema20/11 q33 c Arteriosclerosis d Deep-vein thrombosis 80 The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse? a Bounding b Normal 20/14 q 40 c Weak d Absent 81 The nurse is percussing the seventh right intercostals space at the midclavicular line over the live. Which sound should the nurse expect to hear? a Dullness21/1 q 1 b Tympani c Resonance d Hyper resonance 82 Which structure is located in the left lower quadrant of the abdomen? a Liver b Duodenum c Gallbladder d Sigmoid colon21/1 q 2 83 The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a “We need to determine the areas of tenderness before using percussion and palpation.” b “Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.” 21/4 q11 c “Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination.” d “Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation.” 84 During an abdominal assessment, the nurse would consider which of these findings as normal? a Presence of a bruit in the femoral area b Tympanic percussion note in the umbilical region 21/5 q14 c Palpable spleen between the ninth and eleventh ribs in the left mid-axillary line d Dull percussion note in the left upper quadrant at the midclavicular line 85 The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: a Flatness, resonance, and dullness. b Resonance, dullness, and tympani. c Tympani, hyper resonance, and dullness. 21/5 q 16 d Resonance, hyper resonance, and flatness. 86 A patient is complaining of a sharp pain along the costovertebral angle. The nurse is aware that the symptom is most often indicative: a Ovary infection b Liver enlargement c Kidney inflammation 21/6 q18 d Spleen enlargement 87 A nurse notices that a patient has ascites, which indicates the presence of: a Fluid.21/6 q19 b Feces. c Flatus. d Fibroid tumors. 88 During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? a Spleen b Sigmoid c Appendix 21/7 q 22 d Gallbladder 89 A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a Document the presence of hepatomegaly. b Ask additional health history questions regarding his alcohol intake. c Describe this dullness as indicative of an enlarged liver, and refer him to a physician. d Consider this finding as normal, and proceed with the examination. 21/11 q32 90 The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: a Examine the tender area first. b Examine the tender area last. 21/13 q 39 c Avoid palpating the tender area. d Palpate the tender area first, and then auscultate for bowel sounds. 91 A 62-year-old man states that his physician told him that he has an “inguinal hernia.” He asks the nurse to explain what a hernia is. The nurse should: a Tell him not to worry and that most men his age develop hernias. b Explain that a hernia is often the result of prenatal growth abnormalities, c Refer him to his physician for additional consultation because the physician made the initial diagnosis. d Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles. 24/3 q 7 92 When the nurse is performing a genital examination on a male patent has an erection. The nurse’s most appropriate action or response is to: a Ask the patient if he would like someone else to examine him. b Continue with the examination as though nothing has happened. c Stop the examination, leave the room while stating that the examination will resume at a later time. d Reassure the patient that this is a normal response and continue with the examination.24/5 q 16 93 While performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow with trans- illumination. On the basis of this finding the nurse would: a Assess the patient for the presence of a hernia. b Suspect the presence of serous fluid in the scrotum.24/7 q 21 c Consider this finding normal, and proceed with the examination. d Refer the patient for evaluation of a mass in the scrotum. 94 When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? a Non-tender subcutaneous plaques b Scrotal area that is dry, scaly, and nodular c Testes that feel oval and movable and are slightly sensitive to compression 24/11 q32 d Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes 95 The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a The rectum is approximately 8 cm long. b The anorectal junction cannot be palpated. 25/1 q 3 c Above the anal canal, the rectum turns anteriorly. d No sensory nerves are in the anal canal or rectum. 96 The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should: a Flex the finger, and slowly insert it toward the umbilicus 25/5 q 15. b First instruct the patient that this procedure will be painful. c Insert an extended index finger at a right angle to the anus. d Place the finger directly into the anus to overcome the tight sphincter. 97 During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling “full,” has a distended abdomen, and states that she has not had a bowel movement “for several day.” The nurse suspects which condition? a Rectal polyp b Fecal impaction 25/11 q 30 c Rectal abscess d Rectal prolapsed 98 During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal? a Cervix 26/1 q 3 b Uterus c Ovaries d Fallopian tubes 99 A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: a Menstrual history, because it is generally nonthreatening. 26/4 q11 b Obstetric history, because it includes the most important information. c Urinary system history, because problems may develop in this area as well. d Sexual history, because discussing it first will build rapport. 100 The nurse is preparing for an internal genitalia examination of a women. Which order of the examination is correct? a Bimanual, speculum, and rectovaginal b Speculum, rectovaginal, and bimanual c Speculum, bimanual, and rectovaginal 26/11 q28 d Rectovaginal, bimanual, and speculum